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Bode C, Preissl S, Hein L, Lother A. Catecholamine treatment induces reversible heart injury and cardiomyocyte gene expression. Intensive Care Med Exp 2024; 12:48. [PMID: 38733526 PMCID: PMC11088585 DOI: 10.1186/s40635-024-00632-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 05/07/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Catecholamines are commonly used as therapeutic drugs in intensive care medicine to maintain sufficient organ perfusion during shock. However, excessive or sustained adrenergic activation drives detrimental cardiac remodeling and may lead to heart failure. Whether catecholamine treatment in absence of heart failure causes persistent cardiac injury, is uncertain. In this experimental study, we assessed the course of cardiac remodeling and recovery during and after prolonged catecholamine treatment and investigated the molecular mechanisms involved. RESULTS C57BL/6N wild-type mice were assigned to 14 days catecholamine treatment with isoprenaline and phenylephrine (IsoPE), treatment with IsoPE and subsequent recovery, or healthy control groups. IsoPE improved left ventricular contractility but caused substantial cardiac fibrosis and hypertrophy. However, after discontinuation of catecholamine treatment, these alterations were largely reversible. To uncover the molecular mechanisms involved, we performed RNA sequencing from isolated cardiomyocyte nuclei. IsoPE treatment resulted in a transient upregulation of genes related to extracellular matrix formation and transforming growth factor signaling. While components of adrenergic receptor signaling were downregulated during catecholamine treatment, we observed an upregulation of endothelin-1 and its receptors in cardiomyocytes, indicating crosstalk between both signaling pathways. To follow this finding, we treated mice with endothelin-1. Compared to IsoPE, treatment with endothelin-1 induced minor but longer lasting changes in cardiomyocyte gene expression. DNA methylation-guided analysis of enhancer regions identified immediate early transcription factors such as AP-1 family members Jun and Fos as key drivers of pathological gene expression following catecholamine treatment. CONCLUSIONS The results from this study show that prolonged catecholamine exposure induces adverse cardiac remodeling and gene expression before the onset of left ventricular dysfunction which has implications for clinical practice. The observed changes depend on the type of stimulus and are largely reversible after discontinuation of catecholamine treatment. Crosstalk with endothelin signaling and the downstream transcription factors identified in this study provide new opportunities for more targeted therapeutic approaches that may help to separate desired from undesired effects of catecholamine treatment.
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Affiliation(s)
- Christine Bode
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Preissl
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lutz Hein
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- BIOSS Centre for Biological Signaling Studies, University of Freiburg, Freiburg, Germany
| | - Achim Lother
- Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
- Interdisciplinary Medical Intensive Care, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Vazirani R, Feltes G, Hoyo RSD, Viana-Llamas MC, Raposeiras-Roubín S, Romero R, Alfonso-Rodríguez E, Uribarri A, Santoro F, Becerra-Muñoz V, Pepe M, Castro-Mejía AF, Signes-Costa J, Gonzalez A, Marín F, Lopez-País J, Cerrato E, Vázquez-Cancela O, Espejo-Paeres C, López Masjuan Á, Velicki L, El-Battrawy I, Ramakrishna H, Fernandez-Ortiz A, Nuñez-Gil IJ. Elevated Troponins after COVID-19 Hospitalization and Long-Term COVID-19 Symptoms: Incidence, Prognosis, and Clinical Outcomes-Results from a Multi-Center International Prospective Registry (HOPE-2). J Clin Med 2024; 13:2596. [PMID: 38731127 PMCID: PMC11084489 DOI: 10.3390/jcm13092596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 03/31/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Acute cardiac injury (ACI) after COVID-19 has been linked with unfavorable clinical outcomes, but data on the clinical impact of elevated cardiac troponin on discharge during follow-up are scarce. Our objective is to elucidate the clinical outcome of patients with elevated troponin on discharge after surviving a COVID-19 hospitalization. Methods: We conducted an analysis in the prospective registry HOPE-2 (NCT04778020). Only patients discharged alive were selected for analysis, and all-cause death on follow-up was considered as the primary endpoint. As a secondary endpoint, we established any long-term COVID-19 symptoms. HOPE-2 stopped enrolling patients on 31 December 2021, with 9299 patients hospitalized with COVID-19, of which 1805 were deceased during the acute phase. Finally, 2382 patients alive on discharge underwent propensity score matching by relevant baseline variables in a 1:3 fashion, from 56 centers in 8 countries. Results: Patients with elevated troponin experienced significantly higher all-cause death during follow-up (log-rank = 27.23, p < 0.001), and had a higher chance of experiencing long-term COVID-19 cardiovascular symptoms. Specifically, fatigue and dyspnea (57.7% and 62.8%, with p-values of 0.009 and <0.001, respectively) are among the most common. Conclusions: After surviving the acute phase, patients with elevated troponin on discharge present increased mortality and long-term COVID-19 symptoms over time, which is clinically relevant in follow-up visits.
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Affiliation(s)
- Ravi Vazirani
- Cardiology Department, Hospital Clínico San Carlos, 28040 Madrid, Spain; (R.V.); (A.F.-O.)
| | - Gisela Feltes
- Cardiology Department, Hospital Vithas Arturo Soria, 28043 Madrid, Spain;
| | - Rafael Sánchez-del Hoyo
- Research Methodological Support Unit and Preventive Department, Hospital Clínico San Carlos, IdISSC, 28040 Madrid, Spain;
| | - María C. Viana-Llamas
- Cardiology Department, Hospital Universitario de Guadalajara, 19002 Guadalajara, Spain;
| | | | - Rodolfo Romero
- Emergency Department, Hospital Isabel Zendal, Hospital Universitario de Getafe, 28905 Madrid, Spain;
- Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
| | - Emilio Alfonso-Rodríguez
- Cardiology Department, Bellvitge Biomedical Research Institute (IDIBELL), Hospital Universitario de Bellvitge, 08908 Barcelona, Spain;
| | - Aitor Uribarri
- Cardiology Department, Hospital Universitari Vall d’Hebron, 08035 Barcelona, Spain
| | | | - Víctor Becerra-Muñoz
- Cardiology Department, Hospital Clínico Universitario Virgen de la Victoria, 29010 Malaga, Spain;
| | - Martino Pepe
- Division of Cardiology, Department of Interdisciplinary Medicine (D.I.M.), University of Bari Aldo Moro, 70121 Bari, Italy;
| | - Alex F. Castro-Mejía
- Hospital General del Norte de Guayaquil IESS “Los Ceibos”, Guayaquil 090615, Ecuador;
| | - Jaime Signes-Costa
- Pneumology Department, Hospital Clínico de Valencia, INCLIVA, University of Valencia, 46010 Valencia, Spain;
| | - Adelina Gonzalez
- Anesthesiology Department, Hospital Universitario Infanta Sofia, 28702 Madrid, Spain;
| | - Francisco Marín
- Cardiology Department, Hospital Clínico Universitario Virgen de la Arrixaca, IMIB-Arrixaca, CIBERCV, 30120 Murcia, Spain;
| | - Javier Lopez-País
- Cardiology Department, Complejo Hospitalario Universitario de Ourense, 32004 Orense, Spain;
| | - Enrico Cerrato
- Cardiology Department, San Luigi Gonzaga University Hospital, Orbassano and Rivoli Infermi Hospital, 10098 Rivoli, Italy;
| | - Olalla Vázquez-Cancela
- Preventive Department, Hospital Universitario de Santiago de Compostela, 15706 Santiago de Compostela, Spain;
| | - Carolina Espejo-Paeres
- Cardiology and Emergency Department, Hospital Universitario Príncipe de Asturias, 28805 Madrid, Spain;
| | - Álvaro López Masjuan
- Cardiology Department, Hospital Universitario Juan Ramón Jimenez, 21005 Huelva, Spain;
| | - Lazar Velicki
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia;
- Institute of Cardiovascular Diseases Vojvodina, 21204 Sremska Kamenica, Serbia
| | - Ibrahim El-Battrawy
- Institute of Physiology, Department of Cellular and Translational Physiology, Medical Faculty, Ruhr University of Bochum, 44801 Bochum, Germany;
- Institut für Forschung und Lehre (IFL),Molecular and Experimental Cardiology, Ruhr University of Bochum, 44801 Bochum, Germany
- Department of Cardiology, St. Josef-Hospital of the Ruhr University Bochum, 44801 Bochum, Germany
| | | | | | - Ivan J. Nuñez-Gil
- Cardiology Department, Hospital Clínico San Carlos, 28040 Madrid, Spain; (R.V.); (A.F.-O.)
- Faculty of Biomedical and Health Sciences, Universidad Europea de Madrid, 28670 Villaviciosa de Odón, Spain
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Morgan H, Ezad SM, Rahman H, De Silva K, Partridge JSL, Perera D. Assessment and Management of Ischaemic Heart Disease in Non-Cardiac Surgery. Heart Int 2023; 17:19-26. [PMID: 38419719 PMCID: PMC10898586 DOI: 10.17925/hi.2023.17.2.19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 10/18/2023] [Indexed: 03/02/2024] Open
Abstract
In the setting of non-cardiac surgery, cardiac complications contribute to over a third of perioperative deaths. With over 230 million major surgeries performed annually, and an increasing prevalence of cardiovascular risk factors and ischaemic heart disease, the incidence of perioperative myocardial infarction is also rising. The recent European Society of Cardiology guidelines on cardiovascular risk in noncardiac surgery elevated practices aiming to identify those at most risk, including biomarker monitoring and stress testing. However the current evidence base on if, and how, the risk of cardiac events can be modified is lacking. This review focuses on patient, surgical and cardiac risk assessment, as well as exploring the data on perioperative revascularization and other risk-reduction strategies.
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Affiliation(s)
- Holly Morgan
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Saad M Ezad
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Haseeb Rahman
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Kalpa De Silva
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
| | - Judith S L Partridge
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Divaka Perera
- British Heart Foundation Centre of Research Excellence at the School of Cardiovascular and Metabolic Medicine and Sciences, King's College, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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4
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Binu AJ, Kapoor N, Bhattacharya S, Kishor K, Kalra S. Sarcopenic Obesity as a Risk Factor for Cardiovascular Disease: An Underrecognized Clinical Entity. Heart Int 2023; 17:6-11. [PMID: 38419720 PMCID: PMC10897945 DOI: 10.17925/hi.2023.17.2.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/15/2023] [Indexed: 03/02/2024] Open
Abstract
Sarcopenic obesity (SO) is a chronic condition and an emerging health challenge, in view of the growing elderly population and the obesity epidemic. Due to a lack of awareness among treating doctors and the non-specific nauture of the associated symptoms, SO remains grossly underdiagnosed. There is no consensus yet on a standard definition or diagnostic criteria for SO, which limits the estimation of the global prevalence of this condition. It has been linked to numerous metabolic derangements, cardiovascular disease (CVD) and mortality. The treatment of SO is multimodal and requires expertise across multiple specialties. While dietary modifications and exercise regimens have shown a potential therapeutic benefit, there is currently no proven pharmacological management for SO. However, numerous drugs and the role of bariatric surgery are still under trial, and have great scope for further research. This article covers the available literature regarding the definition, diagnostic criteria, and prevalence of SO, with available evidence linking it to CVD, metabolic disease and mortality, and an overview of current directives on management.
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Affiliation(s)
- Aditya John Binu
- Department of Cardiology, Christian Medical College, Vellore, India
| | - Nitin Kapoor
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College, Vellore, India
- Non-communicable Disease Unit, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | | | - Kamal Kishor
- Department of Cardiology, Rama Hospital, Karnal, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
- University Center for Research & Development, Chandigarh University, Mohali, India
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5
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Fatemi A, Zahedi M, Yazdooei Y, Daei M, Ansari MM, Sohrabi A, Azizinejad A, Hssanpour MR, Behrouzifar M, Babapour H. Association between high-sensitive cardiac troponin level and coronary artery disease: A systematic review and meta-analysis. JRSM Cardiovasc Dis 2023; 12:20480040231220094. [PMID: 38107554 PMCID: PMC10722913 DOI: 10.1177/20480040231220094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/15/2023] [Accepted: 11/24/2023] [Indexed: 12/19/2023] Open
Abstract
Background and objectives Previous studies suggest a link between high-sensitive cardiac troponin (hs-cTn) levels and coronary artery disease (CAD). However, the nature of this relationship is disputed. To address this, we conducted a study to gather and assess evidence on the association between hs-cTn and CAD prediction. Data sources Studies were systematically searched and collected from four databases and different types of gray literature to cover all available evidence. After the screening, the selected articles' quality and risk of bias assessment were evaluated. Synthesis method Meta-analysis calculated std. mean difference on the extracted data. Furthermore, heterogeneity, sensitivity, subgroups, and publication bias analyses were assessed. Results Twenty-two studies were included in this systematic review, with a total of 844 cases and 2101 control people. The results of the meta-analysis on nine studies showed a significant and positive association between hs-cTn levels and CAD (pooled std. mean difference = 0.44; 95% confidence interval = 0.14-0.73; p < 0.003), with no publication bias (p = 0.9170). Among subgroups, std. mean differences were notably different only when the data were stratified by region or risk of bias; however, subgroup analysis could not determine the source of heterogeneity. Conclusions Available prospective studies indicate a strong association of hs-cTn with the risk of CAD and significant improvements in CAD prediction. Further investigations in both molecular and clinical fields with proper methodology and more detailed information are needed to discover more evidence and underlying mechanisms to clear the interactive aspects of hs-cTn level in CAD patients.
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Affiliation(s)
- Alireza Fatemi
- Department of Medical Ethics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Mahdi Zahedi
- Department of cardiology, school of medicine, Golestan University of Medical Sciences, Gorgan, Iran
| | - Yasmin Yazdooei
- Department of Medical Ethics, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Daei
- Alborz university of medical sciences, Alborz, Iran
| | | | - Ahmad Sohrabi
- Infectious Diseases Research Center, Golestan University of Medical Sciences, Gorgan, Iran
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Underestimated Ischemic Heart Disease in Major Adverse Cardiovascular Events after Septicemia Discharge. Medicina (B Aires) 2022; 58:medicina58060753. [PMID: 35744016 PMCID: PMC9230713 DOI: 10.3390/medicina58060753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/30/2022] Open
Abstract
Background and Objectives: Sepsis increases cardiovascular disease and causes death. Ischemic heart disease (IHD) without acute myocardial infarction has been discussed less, and the relationship between risk factors and IHD in septicemia survivors within six months is worthy of in-depth study. Our study demonstrated the incidence of IHD and the possible risk factors for IHD in septicemia patients within six months. Materials and Methods: An inpatient dataset of the Taiwanese Longitudinal Health Insurance Database between 2001 and 2003 was used. The events were defined as rehospitalization of stroke and IHD after discharge or death within six months after the first septicemia hospitalization. The relative factors of major adverse cardiovascular events (MACEs) and IHD were identified by multivariate Cox proportional regression. Results: There were 4323 septicemia survivors and 404 (9.3%) IHD. New-onset atrial fibrillation had a hazard ratio (HR) of 1.705 (95% confidence interval (C.I.): 1.156–2.516) for MACEs and carried a 184% risk with HR 2.836 (95% C.I.: 1.725–4.665) for IHD by adjusted area and other risk factors. Conclusions: This study explored advanced-aged patients who experienced more severe septicemia with new-onset atrial fibrillation, which increases the incidence of IHD in MACEs within six months of septicemia. Therefore, healthcare providers must identify patients with a higher IHD risk and modify risk factors beforehand.
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Bollen Pinto B, Ferrario M, Herpain A, Brunelli L, Bendjelid K, Carrara M, Pastorelli R. Metabolites Concentration in Plasma and Heart Tissue in Relation to High Sensitive Cardiac Troponin T Level in Septic Shock Pigs. Metabolites 2022; 12:metabo12040319. [PMID: 35448505 PMCID: PMC9024493 DOI: 10.3390/metabo12040319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 03/28/2022] [Accepted: 03/30/2022] [Indexed: 12/10/2022] Open
Abstract
Elevated circulating cardiac troponin T (cTnT) is frequent in septic shock patients. Signs of myocardial ischemia and myocyte necrosis are not universally present, but the precise mechanism for elevated cTnT is unknown. We investigated plasma and heart tissue metabolites concentration in six septic shock (SS) and three sham swine undergoing a protocol of polymicrobial septic shock and resuscitation, in order to highlight possible pathways and biomarkers involved in troponin release (high sensitive cardiac troponin T, hs-cTnT). The animals were divided into two groups: the high cTnT group (n = 3) were pigs showing a significantly higher concentration of cTnT and lactate after resuscitation; the low cTnT group (n = 6, three sham and three septic shock) characterized by a lower value of cTnT and a lactate level < 2 mmol/L. Spearman correlation was assessed on plasma fold-change of cTnT, cytokines (TNF-α and IL-10), and metabolites. Finally, the fold-change between the end of resuscitation and baseline values (Res./BL) of plasma metabolites was used to perform a partial least square discriminant analysis (PLS-DA) with three latent variables. Before building the model, the number of features was reduced by summing up the metabolites of the same class that resulted similarly correlated to cTnT fold-change. Proline and glycine were significantly higher in the high cTnT group at the end of experiment both in the myocardium and plasma analyses. Moreover, plasma proline fold-change was found to be positively correlated with cTnT and cytokine fold-changes, and trans-4-hydroxyproline (t4-OH-Pro) fold-change was positively correlated with cTnT fold-change. The PLS-DA model was able to separate the two groups and, among the first ranked features based on VIP score, we found sugars, t4-OH-Pro, proline, creatinine, total amount of sphingomyelins, and glycine. Proline, t4-OH-Pro, and glycine are very abundant in collagen, and our results may suggest that collagen degradation could represent a possible mechanism contributing to septic myocardial injury. The common phenotype of septic cardiomyopathy could be associated to dysregulated collagen metabolism and/or degradation, further exacerbated by higher inflammation and oxidative stress.
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Affiliation(s)
- Bernardo Bollen Pinto
- Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (B.B.P.); (K.B.)
- Geneva Perioperative Basic, Translational and Clinical Research Group, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Manuela Ferrario
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy;
- Correspondence:
| | - Antoine Herpain
- Department of Intensive Care, Erasme University Hospital—Université Libre de Bruxelles, 1070 Brussels, Belgium;
- Experimental Laboratory of Intensive Care—Erasme University Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium
| | - Laura Brunelli
- Laboratory of Mass Spectrometry, Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (L.B.); (R.P.)
| | - Karim Bendjelid
- Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland; (B.B.P.); (K.B.)
- Department of Anesthesiology, Pharmacology and Intensive Care, Geneva Hemodynamic Research Group, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Marta Carrara
- Department of Electronics, Information and Bioengineering, Politecnico di Milano, 20133 Milan, Italy;
| | - Roberta Pastorelli
- Laboratory of Mass Spectrometry, Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy; (L.B.); (R.P.)
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Temiz Artmann A, Kurulgan Demirci E, Fırat IS, Oflaz H, Artmann GM. Recombinant Activated Protein C (rhAPC) Affects Lipopolysaccharide-Induced Mechanical Compliance Changes and Beat Frequency of mESC-Derived Cardiomyocyte Monolayers. Shock 2022; 57:544-552. [PMID: 34416756 PMCID: PMC8906254 DOI: 10.1097/shk.0000000000001845] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/17/2021] [Accepted: 08/03/2021] [Indexed: 12/07/2022]
Abstract
BACKGROUND Septic cardiomyopathy increases mortality by 70% to 90% and results in mechanical dysfunction of cells. METHODS Here, we created a LPS-induced in-vitro sepsis model with mouse embryonic stem cell-derived cardiomyocytes (mESC-CM) using the CellDrum technology which simultaneously measures mechanical compliance and beat frequency of mESCs. Visualization of reactive oxygen species (ROS), actin stress fibers, and mRNA quantification of endothelial protein C receptor (EPCR) and protease-activated receptor 1 (PAR1) before/after LPS incubation were used for method validation. Since activated protein C (APC) has cardioprotective effects, samples were treated with human recombinant APC (rhAPC) with/-out LPS predamage to demonstrate the application in therapeutic studies. RESULTS Twelve hours LPS treatment (5 μg/mL) increased ROS and decreased actin stress fiber density and significantly downregulated EPCR and PAR1 compared to control samples (0.26, 0.39-fold respectively). rhAPC application (5 μg/mL, 12 h) decreased ROS and recovered actin density, EPCR, and PAR1 levels were significantly upregulated compared to LPS predamaged samples (4.79, 3.49-fold respectively). The beat frequencies were significantly decreased after 6- (86%) and 12 h (73%) of LPS application. Mechanical compliance of monolayers significantly increased in a time-dependent manner, up to eight times upon 12-h LPS incubation compared to controls. rhAPC incubation increased the beat frequency by 127% (6h-LPS) and 123% (12h-LPS) and decreased mechanical compliance by 68% (12h-LPS) compared to LPS predamaged samples. CONCLUSION LPS-induced contraction dysfunction and the reversal effects of rhAPC were successfully assessed by the mechanical properties of mESC-CMs. The CellDrum technology proved a decent tool to simulate sepsis in-vitro.
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Affiliation(s)
- Aysegül Temiz Artmann
- Institute for Bioengineering, University of Applied Sciences Aachen/Campus Juelich, Juelich, Germany
| | - Eylem Kurulgan Demirci
- Institute for Bioengineering, University of Applied Sciences Aachen/Campus Juelich, Juelich, Germany
- Department of Chemistry, Faculty of Science, Izmir Institute of Technology, Campus Gulbahce, URLA, Izmir, Turkey
| | - Ipek Seda Fırat
- Institute for Bioengineering, University of Applied Sciences Aachen/Campus Juelich, Juelich, Germany
| | - Hakan Oflaz
- Bioengineering Department, Faculty of Engineering, Gebze Technical University, Kocaeli, Turkey
| | - Gerhard M. Artmann
- Institute for Bioengineering, University of Applied Sciences Aachen/Campus Juelich, Juelich, Germany
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Innocenti F, Palmieri V, Stefanone VT, D'Argenzio F, Cigana M, Montuori M, Capretti E, De Paris A, Calcagno S, Tassinari I, Pini R. Comparison of Troponin I levels versus myocardial dysfunction on prognosis in sepsis. Intern Emerg Med 2022; 17:223-231. [PMID: 33730362 DOI: 10.1007/s11739-021-02701-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 03/08/2021] [Indexed: 10/21/2022]
Abstract
In the context of sepsis, we tested the relationship between echocardiographic findings and Troponin, and their impact on prognosis. In this prospective study, we enrolled 325 septic patients (41% with shock), not mechanically ventilated, between October, 2012 and June, 2019 among those admitted to our High-Dependency Unit. By echocardiography within 24 h from the admission, sepsis-induced myocardial dysfunction (SIMD) was defined as left ventricular (LV) systolic dysfunction (speckle-tracking-based global longitudinal peak systolic strain, GLS, > - 14%) and/or right ventricular (RV) systolic dysfunction (Tricuspid Annular Plane Systolic Excursion, TAPSE < 16 mm). Troponin I levels were measured upon admission (T0) and after 24 h (T1); it was considered normal if > 0.1 ng/mL. Mortality was assessed at day-7 and day-28 end-points. One-hundred and forty-two patients had normal Troponin level at T0 and T1 (G1), 69 had abnormal levels at T0 or T1 (G2) and 114 showed abnormal Troponin levels at both T0 and T1 (G3). Compared to G1, patients in G3 had worse LV and RV systolic function (GLS - 11.6 ± 3.4% vs - 14.0 ± 3.5%, p < 0.001; TAPSE 18 ± 0.5 vs 19 ± 0.5 mm, p = 0.047) and greater day-28 (34% vs 20%, p = 0.015) mortality. In a Cox survival analysis including age, Troponin and SOFA score, mortality was predicted by the presence of SIMD (RR 3.24, 95% CI 1.72-6.11, p < 0.001) with no contribution of abnormal Troponin level. While abnormal Troponin levels were associated with SIMD diagnosed by echocardiography, only the presence of SIMD predicted the short- and medium-term mortality rate, without an independent contribution of increased Troponin levels.
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Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy.
| | - Vittorio Palmieri
- Transplant Cardiosurgery Unit, Department of Cardiac Surgery and Transplant, Ospedale Dei Colli Monaldi-Cotugno-CTO, Naples, Italy
| | - Valerio Teodoro Stefanone
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Federico D'Argenzio
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Marco Cigana
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Michele Montuori
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Elisa Capretti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Anna De Paris
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Stefano Calcagno
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Irene Tassinari
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
| | - Riccardo Pini
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Firenze, Italy
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10
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Paana T, Jaakkola S, Biancari F, Nuotio I, Vasankari T, Kiviniemi TO, Airaksinen KEJ. Minor troponin T elevation and mortality in patients with atrial fibrillation presenting to the emergency department. Eur J Clin Invest 2021; 51:e13590. [PMID: 34002383 DOI: 10.1111/eci.13590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 04/25/2021] [Accepted: 05/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are limited data on the association of minor troponin elevation in unselected patients with atrial fibrillation (AF) presenting to the emergency department (ED) with adverse events. In this study, we sought to assess the early and mid-term mortality of these patients. METHODS In this observational study, 2911 patients with AF were admitted to the ED. They were divided into 3 groups based on peak high-sensitivity troponin (TnT) levels: normal (<15 ng/L), 15-50 ng/L and 51-100 ng/L. The primary outcomes of this study were all-cause mortality at 30 days and 1 year. RESULTS All-cause mortality was 6.7% (n = 196) at 30 days and 22.2% (n = 646) at 1 year. Mortality rate increased along with increasing levels of TnT irrespective of baseline covariates, primary discharge diagnosis and type of AF. A significant association between TnT levels and all-cause mortality was observed. The adjusted hazard ratio (HR) at 30 days was 6.02 (95% CI 2.62-13.83) for TnT 15-50 ng/L and 11.28 (95% CI 4.87-26.12) for TnT 51-100 ng/L (P<.001 for both) compared to TnT <15 ng/L. At 1 year, the adjusted HRs were 3.08 (95% CI 2.15-4.40) and 5.07 (95% CI 3.49-7.35), respectively (P < .001). When patients with TnT <15 ng/L were divided into two groups at the median value, TnT elevation of 10 to 14 ng/L was also associated with increased 1-year mortality (HR 2.51; 95% CI 1.09-5.74; P = .03). CONCLUSIONS Among patients with AF admitted to the ED, increased TnT levels were associated with increased early and mid-term all-cause mortality irrespective of baseline covariates and type of AF.
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Affiliation(s)
- Tuomas Paana
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Samuli Jaakkola
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Fausto Biancari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland.,Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
| | - Ilpo Nuotio
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Department of Acute Internal Medicine, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuija Vasankari
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland
| | - Tuomas O Kiviniemi
- Heart Center, Turku University Hospital and University of Turku, Turku, Finland.,Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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11
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Biswas S, Soneja M, Makkar N, Farooqui FA, Roy A, Kumar A, Nischal N, Biswas A, Wig N, Sood R, Sreenivas V. N-terminal pro-brain natriuretic peptide is an independent predictor of mortality in patients with sepsis. J Investig Med 2021; 70:369-375. [PMID: 34702775 DOI: 10.1136/jim-2021-002017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2021] [Indexed: 11/04/2022]
Abstract
This study aims to evaluate the role of cardiac enzymes N-terminal pro-brain natriuretic peptide (NT-proBNP) and cardiac troponin-I (CTnI) as predictors of outcomes in patients with sepsis.78 cases with a diagnosis of sepsis were enrolled over a 2-year period. Baseline demographic, Acute Physiology and Chronic Health Evaluation-II (APACHE-II), Simplified Acute Physiology Score-II (SAPS-II), hematologic and biochemical parameters were noted. Serum NT-proBNP and CTnI were evaluated at 24 and 72 hours of admission along with echocardiography. Patients were prospectively followed up until death or discharge.Mean APACHE-II score was 19.8±9.6 and SAPS-II was 44.8±17.2. Survival rate in the study was 47.5% (36 of 78 patients). NT-proBNP was significantly higher in non-survivors with values over 4300 pg/mL at 24 hours and 5229 pg/mL at 72 hours associated with poor outcomes (p<0.05). CTnI was higher among non-survivors than in survivors, but the difference was not significant. APACHE-II score combined with NT-proBNP predicted a poor outcome in 51.2% cases compared with 14.6% cases with APACHE-II alone (p<0.05), while SAPS-II combined with NT-proBNP predicted a poor outcome in 53.6% cases as compared with 9.6% cases with SAPS-II alone (p<0.05). SAPS-II greater than 45 and NT-proBNP values at 72 hours were independent predictors of mortality in patients with sepsis.NT-proBNP is an independent predictor of mortality in patients with sepsis and its combination with APACHE-II and SAPS-II improves the predictive values of the scoring systems.
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Affiliation(s)
- Sagnik Biswas
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Manish Soneja
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayani Makkar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Faraz Ahmed Farooqui
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ambuj Roy
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, India
| | - Arvind Kumar
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Neeraj Nischal
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ashutosh Biswas
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Naveet Wig
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rita Sood
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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12
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The relationship between coronary artery disease and clinical outcomes in COVID-19: a single-center retrospective analysis. Coron Artery Dis 2021; 32:367-371. [PMID: 32732512 DOI: 10.1097/mca.0000000000000934] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Recent studies have reported evidence that coronavirus disease 2019 (COVID-19) has disproportionately affected patients with underlying comorbidities. Our study aims to evaluate the impact of both cardiac and noncardiac comorbidities on a high-risk population with COVID-19 infection and coronary artery disease (CAD) compared to those without CAD. METHODS This is a retrospective study of patients who tested COVID-19 positive via reverse transcriptase-PCR (RT-PCR) assay. We compared the characteristics and outcomes of patients with and without CAD. Population demographics, comorbidities and clinical outcomes were collected and analyzed. Multivariate logistic regression analysis was used to identify factors associated with inpatient mortality. RESULTS A final sample population of 355 patients was identified, 77 of which had a known diagnosis of coronary artery disease. Our study population had a higher proportion of females, and those with CAD were significantly older. The rates of cardiovascular risk factors including hypertension, diabetes mellitus and chronic kidney disease, as well as heart failure and chronic obstructive pulmonary disease were significantly higher in the CAD population. Lactate dehydrogenase was the only inflammatory marker significantly lower in the CAD group, while troponin and brain natriuretic peptide were significantly higher in this population. Patients with CAD also had significantly higher inpatient mortality (31% vs 20%, P = 0.046) and need for renal replacement therapy (33% vs 11%, P < 0.0001) compared to the non-CAD group. However, only age [odds ratio 1.041 (1.017-1.066), P = 0.001] was significantly associated with mortality in the overall population after adjusting for demographics and comorbidities, while the presence of CAD was not independently associated with mortality. CONCLUSION Patients with CAD and COVID-19 have higher rates of comorbidities, inpatient mortality and need for renal replacement therapy compared to their non-CAD counterparts. However, CAD in itself was not associated with mortality after adjusting for other covariates, suggesting that other factors may play a larger role in the increased mortality and poor outcomes in these patients.
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13
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Calvo-Fernández A, Izquierdo A, Subirana I, Farré N, Vila J, Durán X, García-Guimaraes M, Valdivielso S, Cabero P, Soler C, García-Ribas C, Rodríguez C, Llagostera M, Mojón D, Vicente M, Solé-González E, Sánchez-Carpintero A, Tevar C, Marrugat J, Vaquerizo B. Markers of myocardial injury in the prediction of short-term COVID-19 prognosis. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:576-583. [PMID: 33153955 PMCID: PMC7522647 DOI: 10.1016/j.rec.2020.09.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/14/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION AND OBJECTIVES COVID-19 is currently causing high mortality and morbidity worldwide. Information on cardiac injury is scarce. We aimed to evaluate cardiovascular damage in patients with COVID-19 and determine the correlation of high-sensitivity cardiac-specific troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) with the severity of COVID-19. METHODS We included 872 consecutive patients with confirmed COVID-19 from February to April 2020. We tested 651 patients for high-sensitivity troponin T (hs-TnT) and 506 for NT-proBNP on admission. Cardiac injury was defined as hs-TnT> 14ng/L, the upper 99th percentile. Levels of NT-proBNP> 300 pg/mL were considered related to some extent of cardiac injury. The primary composite endpoint was 30-day mortality or mechanical ventilation (MV). RESULTS Cardiac injury by hs-TnT was observed in 34.6% of our COVID-19 patients. Mortality or MV were higher in cardiac injury than noncardiac injury patients (39.1% vs 9.1%). Hs-TnT and NT-proBNP levels were independent predictors of death or MV (HR, 2.18; 95%CI, 1.23-3.83 and 1.87 (95%CI, 1.05-3.36), respectively) and of mortality alone (HR, 2.91; 95%CI, 1.211-7.04 and 5.47; 95%CI, 2.10-14.26, respectively). NT-ProBNP significantly improved the troponin model discrimination of mortality or MV (C-index 0.83 to 0.84), and of mortality alone (C-index 0.85 to 0.87). CONCLUSIONS Myocardial injury measured at admission was a common finding in patients with COVID-19. It reliably predicted the occurrence of mortality and need of MV, the most severe complications of the disease. NT-proBNP improved the prognostic accuracy of hs-TnT.
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Affiliation(s)
- Alicia Calvo-Fernández
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Andrea Izquierdo
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Isaac Subirana
- Centro de Investigaciones Biomédicas en Red Epidemiología y Salud Pública (CIBERESP), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Epidemiología y Genética Cardiovascular, Grupo REGICOR, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain
| | - Nuria Farré
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Joan Vila
- Epidemiología y Genética Cardiovascular, Grupo REGICOR, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Xavier Durán
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain
| | - Marcos García-Guimaraes
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | | | - Paula Cabero
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - Cristina Soler
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | | | | | | | - Diana Mojón
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Miren Vicente
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | | | - Andrea Sánchez-Carpintero
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain
| | - Cristina Tevar
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain
| | - Jaume Marrugat
- Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain; Centro de Investigaciones Biomédicas en Red Epidemiología y Salud Pública (CIBERESP), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Epidemiología y Genética Cardiovascular, Grupo REGICOR, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain
| | - Beatriz Vaquerizo
- Servicio de Cardiología, Hospital del Mar, Barcelona, Spain; Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, Spain; Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain.
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14
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Calvo-Fernández A, Izquierdo A, Subirana I, Farré N, Vila J, Durán X, García-Guimaraes M, Valdivielso S, Cabero P, Soler C, García-Ribas C, Rodríguez C, Llagostera M, Mojón D, Vicente M, Solé-González E, Sánchez-Carpintero A, Tevar C, Marrugat J, Vaquerizo B. [Markers of myocardial injury in the prediction of short-term COVID-19 prognosis]. Rev Esp Cardiol 2021; 74:576-583. [PMID: 33262553 PMCID: PMC7691144 DOI: 10.1016/j.recesp.2020.09.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/14/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION AND OBJECTIVES COVID-19 is currently causing high mortality and morbidity worldwide. Information on cardiac injury is scarce. We aimed to evaluate cardiovascular damage in patients with COVID-19 and determine the correlation of high-sensitivity cardiac-specific troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) with the severity of COVID-19. METHODS We included 872 consecutive patients with confirmed COVID-19 from February to April 2020. We tested 651 patients for high-sensitivity troponin T (hs-TnT) and 506 for NT-proBNP on admission. Cardiac injury was defined as hs-TnT > 14 ng/L, the upper 99th percentile. Levels of NT-proBNP > 300 pg/mL were considered related to some extent of cardiac injury. The primary composite endpoint was 30-day mortality or mechanical ventilation (MV). RESULTS Cardiac injury by hs-TnT was observed in 34.6% of our COVID-19 patients. Mortality or MV were higher in cardiac injury than noncardiac injury patients (39.1% vs 9.1%). Hs-TnT and NT-proBNP levels were independent predictors of death or MV (HR, 2.18; 95%CI, 1.23-3.83 and 1.87 (95%CI, 1.05-3.36), respectively) and of mortality alone (HR, 2.91; 95%CI, 1.211-7.04 and 5.47; 95%CI, 2.10-14.26, respectively). NT-ProBNP significantly improved the troponin model discrimination of mortality or MV (C-index 0.83 to 0.84), and of mortality alone (C-index 0.85 to 0.87). CONCLUSIONS Myocardial injury measured at admission was a common finding in patients with COVID-19. It reliably predicted the occurrence of mortality and need of MV, the most severe complications of the disease. NT-proBNP improved the prognostic accuracy of hs-TnT.
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Affiliation(s)
- Alicia Calvo-Fernández
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
- Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Andrea Izquierdo
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
- Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Isaac Subirana
- Centro de Investigaciones Biomédicas en Red Epidemiología y Salud Pública (CIBERESP), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
- Epidemiología y Genética Cardiovascular, Grupo REGICOR, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
| | - Nuria Farré
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
- Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
- Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - Joan Vila
- Epidemiología y Genética Cardiovascular, Grupo REGICOR, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - Xavier Durán
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
| | - Marcos García-Guimaraes
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
- Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | | | - Paula Cabero
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
- Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - Cristina Soler
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
- Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | | | - Clara Rodríguez
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
| | - Marc Llagostera
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
| | - Diana Mojón
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
| | - Miren Vicente
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
| | | | - Andrea Sánchez-Carpintero
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
| | - Cristina Tevar
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
| | - Jaume Marrugat
- Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
- Centro de Investigaciones Biomédicas en Red Epidemiología y Salud Pública (CIBERESP), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
- Epidemiología y Genética Cardiovascular, Grupo REGICOR, Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
| | - Beatriz Vaquerizo
- Servicio de Cardiología, Hospital del Mar, Barcelona, España
- Departamento de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Hospital del Mar, Barcelona, España
- Grupo de Investigación en Enfermedades del Corazón (GREC), Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
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15
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Tarquinio N, Viticchi G, Zaccone V, Martino M, Fioranelli A, Morciano P, Moroncini G, Di Pentima C, Martini A, Nitti C, Salvi A, Burattini M, Falsetti L. The value of admission Troponin I to predict outcomes in suspected infections in elderly patients admitted in Internal Medicine: results from the SOFA-T collaboration, a multi-center study. Intern Emerg Med 2021; 16:981-988. [PMID: 33428111 DOI: 10.1007/s11739-020-02610-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 12/16/2020] [Indexed: 01/24/2023]
Abstract
Elderly patients affected by suspected infection and declining clinical conditions can be admitted to stepdown units (SDU), but a risk stratification is necessary to optimize their management. Admission troponin I (aTnI) has a prognostic role, however, one of the most commonly used stratification tools, the Sequential Organ Failure Assessment score (SOFA), does not consider myocardial injury. With this paper, we aimed to evaluate the prognostic accuracy of a new score, named SOFA-T, considering both SOFA score and aTnI in a cohort of elderly patients admitted to the stepdown beds of two Internal Medicine departments. Patients aged > 65 years admitted in SDU of two different hospitals of the same region in a 12-months timeframe were retrospectively assessed obtaining age, sex, days of admission, in-hospital death, SOFA, aTnI and comorbidities. The best aTnI cutoff for in-hospital death was calculated with ROC curve analysis; dichotomous variables were compared with chi-squared test; continuous variables were compared with t test or Mann-Whitney test. We obtained a cohort of 390 patients. The best aTnI cutoff was 0.31 ng/ml: patients with increased aTnI had higher risk of in-hospital death (OR: 1.834; 95% CI 1.160-2.900; p = 0.009), and higher SOFA (6.81 ± 2.71 versus 5.97 ± 3.10; p = 0.010). Adding aTnI to SOFA increased significantly the area under the curve (AUCSOFA = 0.68; 95% CI 0.64-0.73; AUCSOFA-T = 0.71; 95% CI 0.65-0.76; p = 0.0001), with a slight improvement of the prognostic performance. In elderly patients admitted to SDU for suspected infection, sepsis or septic shock, aTnI slightly improves the accuracy of SOFA score of the in-hospital death prediction.
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Affiliation(s)
- N Tarquinio
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - G Viticchi
- Clinica Di Neurologia, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Italy, Ancona, Italy
| | - V Zaccone
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy
| | - M Martino
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - A Fioranelli
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - P Morciano
- Emergency Medicine Residency Program, Marche Polytechnic University, Ancona, Italy
| | - G Moroncini
- Clinica Medica, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Italy, Ancona, Italy
| | - C Di Pentima
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - A Martini
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - C Nitti
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy
| | - A Salvi
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy
| | - M Burattini
- Internal Medicine Department, INRCA-IRCCS Hospital, Osimo, Ancona, Italy
| | - L Falsetti
- Internal and Subintensive Medicine Department, Azienda Ospedaliero-Universitaria "Ospedali Riuniti" Di Ancona, Via Conca 10, Ancona, Italy.
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16
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Horiuchi Y, Wettersten N, Maisel A. Response by Horiuchi et al to Letter Regarding Article, "Biomarkers Enhance Discrimination and Prognosis of Type 2 Myocardial Infarction". Circulation 2021; 143:e252-e253. [PMID: 33617307 DOI: 10.1161/circulationaha.120.051634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Yu Horiuchi
- University of California, San Diego, La Jolla (Y.H., N.W., A.M.).,Mitsui Memorial Hospital, Tokyo, Japan (Y.H.)
| | | | - Alan Maisel
- University of California, San Diego, La Jolla (Y.H., N.W., A.M.)
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17
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Hinton J, Gabara L, Curzen N. Is the true clinical value of high-sensitivity troponins as a biomarker of risk? The concept that detection of high-sensitivity troponin 'never means nothing'. Expert Rev Cardiovasc Ther 2020; 18:843-857. [PMID: 32966128 DOI: 10.1080/14779072.2020.1828063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION High-sensitivity troponin (hs-cTn) assays are central to the diagnosis of myocardial infarction (MI). Their increased sensitivity has facilitated rapid pathways for the exclusion of MI. However, hs-cTn is now more readily detectable in patients without symptoms typical of MI, in whom a degree of myocardial injury is assumed. Recently, the practice of using the 99th centile of hs-cTn as a working 'upper reference limit' has been challenged. There is increasing evidence that hs-cTn may provide useful prognostic information, regardless of any suspicion of MI, and as such these assays may have potential as a general biomarker for mortality. This raises the concept that detection of hs-cTn 'never means nothing.' AREAS COVERED In this review, we will evaluate the evidence for the use of hs-cTn assays outside their common clinical indication to rule out or diagnose acute MI. EXPERT OPINION The data presented suggest that hs-cTn testing may in the future have a generalized role as a biomarker of mortality risk and may be used less as a test for ruling in acute MI, but will remain a frontline test to exclude that diagnosis in ED. Further, the data suggest that the detection of hs-cTn 'never means nothing.'
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Affiliation(s)
- Jonathan Hinton
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Lavinia Gabara
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
| | - Nick Curzen
- Coronary Research Group, University Hospital Southampton NHS Foundation Trust , Southampton, UK.,Faculty of Medicine, University of Southampton , Southampton, UK
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18
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Abstract
OBJECTIVE To investigate the behavior of pentraxin-3 (PTX3), troponin T (hsTnT), N-terminal pro-B type Natriuretic Peptide (NT-proBNP) in sepsis and their relationships with sepsis severity and oxygen transport/utilization impairment. DESIGN Retrospective analysis of PTX3, hsTnT, NT-proBNP levels at day 1, 2, and 7 after admission in the intensive care unit in a subset of the Albumin Italian Outcome Sepsis database. SETTING Forty Italian intensive care units. PATIENTS Nine hundred fifty-eight septic patients enrolled in the randomized clinical trial comparing albumin replacement plus crystalloids and crystalloids alone. INTERVENTIONS The patients were divided into sextiles of lactate (marker of severity), ScvO2 (marker of oxygen transport), and fluid balance (marker of therapeutic strategy). MEASUREMENTS AND MAIN RESULTS PTX3 and hsTnT were remarkably similar in the two treatment arms, while NT-proBNP was almost double in the albumin treatment group. However, as the distribution of all these biomarkers was similar between control and treatment arms, for the sake of clarity, we analyzed the patients as a single cohort. PTX3 (71.8 [32.9-186.3] ng/mL), hsTnT (50.4 [21.6-133.6] ng/L), and NT-proBNP (4,393 [1,313-13,837] ng/L) were abnormally elevated in 100%, 84.5%, 93.4% of the 953 patients and all decreased from day 1 to day 7. PTX3 monotonically increased with increasing lactate levels. The hsTnT levels were significantly higher when ScvO2 levels were abnormally low (< 70%), suggesting impaired oxygen transport compared with higher ScvO2 levels, suggesting impaired oxygen utilization. NT-proBNP was higher with higher lactate and fluid balance. At ScvO2 levels < 70%, the NT-proBNP was higher than at higher ScvO2 levels. However, even with higher ScvO2, the NT-proBNP was remarkably elevated, suggesting volume expansion. Increased level of NT-proBNP showed the strongest association with 90-day mortality. CONCLUSIONS The selected biomarkers seem related to different mechanisms during sepsis: PTX3 to sepsis severity, hsTnT to impaired oxygen transport, NT-proBNP to sepsis severity, oxygen transport, and aggressive fluid strategy.
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19
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Bellia C, Lombardo M, Della-Morte D. Use of Troponin as a predictor for cardiovascular diseases in patients with type 2 Diabetes Mellitus. Clin Chim Acta 2020; 507:54-61. [PMID: 32302683 DOI: 10.1016/j.cca.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 10/24/2022]
Abstract
People with type 2 diabetes mellitus (T2DM) have two- to four-fold increased cardiovascular mortality in comparison to the general population. With the identification of new therapeutic targets and hypoglycemic drugs for T2DM, the need for a better stratification of CVD risk has emerged to select patients who may need intensive or specific treatment. At present, risk stratification is based on clinical, demographic, and biochemical factors. High sensitivity cardiac troponin (hs-cTn) increases after several ischemic and non-ischemic insults and it is considered a marker of myocardial injury. This review summarizes the main findings about hs-cTn utilization for risk stratification in people with T2DM and no clinical CVD. Several large observational studies have documented the association between hs-cTn and adverse cardiovascular outcomes in both the general population and in patients with T2DM. Lifestyle interventions, and particularly promotion of physical activity and adoption of healthy nutritional habits, have been associated to a significant benefit on hs-cTn release in the general population. Randomized controlled trials suggested that hypoglycemic, anti-hypertensive and lipid-lowering therapy may influence the degree of T2DM-induced cardiac injury. Besides these promising findings, the efficacy of an hs-cTn-based approach for CVD prevention in T2DM patients still requires more investigations.
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Affiliation(s)
- Chiara Bellia
- Department of Biomedicine, Neurosciences, and Advanced Diagnostics, University of Palermo, Italy.
| | - Mauro Lombardo
- Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Open University, Rome, Italy
| | - David Della-Morte
- Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy; Department of Human Sciences and Quality of Life Promotion, San Raffaele Roma Open University, Rome, Italy; Department of Neurology and Evelyn F. McKnight Brain Institute, Miller School of Medicine, University of Miami, Miami, FL, USA
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20
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Chen C, Werne A, Osborn K, Vo H, George U, Sawe H, Addo N, Tenner A. This Article Corrects: “Effectiveness of a Pediatric Emergency Medicine Curriculum in a Public Tanzanian Referral Hospital”. West J Emerg Med 2020; 21:469. [PMID: 31999251 PMCID: PMC7081880 DOI: 10.5811/westjem.2020.1.46579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Carol Chen
- University of California, San Francisco, Section of Pediatric Emergency Medicine, Department of Emergency Medicine, San Francisco, California
| | - Alexander Werne
- University of California, San Francisco, Department of Pediatrics, San Francisco, California
| | - Katharine Osborn
- University of California, San Francisco, Section of Pediatric Emergency Medicine, Department of Emergency Medicine, San Francisco, California; University of Utah, Division of Emergency Medicine, Department of Pediatrics, Salt Lake City, Utah
| | - Holly Vo
- University of California, San Francisco, Department of Pediatrics, San Francisco, California
| | - Upendo George
- Muhimbili National Hospital, Department of Emergency Medicine, Dar Es Salaam, Tanzania
| | - Hendry Sawe
- Muhimbili National Hospital, Department of Emergency Medicine, Dar Es Salaam, Tanzania
| | - Newton Addo
- University of California, San Francisco, Department of Medicine, Clinical Pharmacology Program, San Francisco, California; University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Andrea Tenner
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
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21
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Lahham S, Lee C, Ali Q, Moeller J, Fischetti C, Thompson M, Saadat S, Fox JC. Tricuspid Annular Plane of Systolic Excursion (TAPSE) for the Evaluation of Patients with Severe Sepsis and Septic Shock. West J Emerg Med 2020; 21:348-352. [PMID: 31999246 PMCID: PMC7081860 DOI: 10.5811/westjem.2019.11.44968] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 11/10/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction Sepsis is a systemic infection that can rapidly progress into multi organ failure and shock if left untreated. Previous studies have demonstrated the utility of point of care ultrasound (POCUS) in the evaluation of patients with sepsis. However, limited data exists on the evaluation of the tricuspid annular plane of systolic excursion (TAPSE) in patients with sepsis. Methods We prospectively enrolled patients who presented to the emergency department (ED) with concern for severe sepsis or septic shock in a pilot study. In patients that screened positive, the treating physician then performed POCUS to measure the TAPSE value. We compared the intensive care unit (ICU) admission rate, hospital length of stay, and morbidity with their respective TAPSE values. Results We enrolled 24 patients in the study. Eight patients had TAPSE values less than 16 millimeters (mm), two patients had TAPSE values between 16mm–20mm, and fourteen patients had TAPSE values greater than 20mm. There was no statistically significant association between TAPSE levels and ICU admission (p=0.16), or death (p=0.14). The difference of length of stay (LOS) was not statistically significant in case of hospital LOS (p= 0.72) or ICU LOS. Conclusion Our pilot data did not demonstrate a correlation between severe sepsis or septic shock and TAPSE values. This may be due to several factors including patient comorbidities, strict definitions of sepsis and septic shock, as well as the absence of septic cardiomyopathy (SCM) in patients with sepsis and septic shock. Future large-scale studies are needed to determine if TAPSE can be beneficial in the ED evaluation of patients with concern for SCM.
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Affiliation(s)
- Shadi Lahham
- University of California, Irvine; Department of Emergency Medicine, Orange, California
| | - Clifton Lee
- University of California, Irvine; Department of Emergency Medicine, Orange, California
| | - Qumber Ali
- University of California, Irvine; Department of Emergency Medicine, Orange, California
| | - John Moeller
- University of California, Irvine; Department of Emergency Medicine, Orange, California
| | - Chanel Fischetti
- University of California, Irvine; Department of Emergency Medicine, Orange, California
| | - Maxwell Thompson
- University of Alabama, Department of Emergency Medicine, Birmingham, Alabama
| | - Soheil Saadat
- University of California, Irvine; Department of Emergency Medicine, Orange, California
| | - John C Fox
- University of California, Irvine; Department of Emergency Medicine, Orange, California
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22
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Etiology of Minor Troponin Elevations in Patients with Atrial Fibrillation at Emergency Department-Tropo-AF Study. J Clin Med 2019; 8:jcm8111963. [PMID: 31739414 PMCID: PMC6912339 DOI: 10.3390/jcm8111963] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 10/31/2019] [Accepted: 11/10/2019] [Indexed: 12/20/2022] Open
Abstract
Patients with atrial fibrillation (AF) presenting to the emergency department (ED) often have elevated cardiac troponin T (TnT) levels without evidence of type 1 myocardial infarction. We sought to explore the causes and significance of minor TnT elevations in patients with AF at the ED. All patients with AF admitted to the ED of Turku University Hospital between 1 March, 2013 and 11 April, 2016, and at least two TnT measurements, were screened. Overall, 2911 patients with a maximum TnT of 100 ng/L during hospitalization were analyzed. TnT was between 15 and 100 ng/L in 2116 patients. The most common primary discharge diagnoses in this group were AF (18.1%), infection (18.3%), ischemic stroke/transient ischemic attack (10.7%), and heart failure (5.0%). Acute coronary syndrome (ACS) was equally uncommon both in patients with normal TnT and elevated TnT (4.4% vs. 4.5%). Age ≥75 years, low estimated glomerular filtration rate (eGFR), high C-reactive protein (CRP), and hemoglobin <10.0 g/dL, were the most important predictors of elevated TnT. Importantly, TnT elevation was a very frequent (>93%) finding in elderly (≥75 years) AF patients with either low eGFR or high CRP. In conclusion, minor TnT elevations carry limited diagnostic value in elderly AF patients with comorbidities.
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23
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Fitzgerald G, Kerley RN, Kiernan TJ. High-sensitivity troponin assays: development and utility in a modern health-care system. Expert Rev Cardiovasc Ther 2019; 17:763-770. [PMID: 31574239 DOI: 10.1080/14779072.2019.1675514] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: The introduction of cardiac troponin (cTn) assays have revolutionized the diagnosis and management of acute myocardial infarction in Emergency Departments worldwide. Its success has led to significant research and development investment in this area culminating in the development of newer high-sensitivity cardiac troponin assays (hs-cTn). While these newer assays allow for more rapid diagnosis by decreasing the time interval between serial data points, there is an inevitable trade off between increasing sensitivity and specificity. This review examines in detail the introduction and implementation of hs-cTN and its implications for clinical practice.Areas covered: This article reviews the history and development of high-sensitivity troponin assays and their application to clinical practice and current evidence base. It also discusses both the positive and negative aspects of the continuing increasing sensitivity of biochemical assays and the translation of this into clinical practice. Potential future developments are also discussed.Expert commentary: It is clear that there are many benefits to detecting extremely low concentration of cardiac troponin including the development of rapid rule out algorithms and the cost and time-saving advantages associated with the quicker movement of patients through the health-care system. It is important to note however that detecting troponin at very low concentrations also dramatically increases the false-positive rates and leads to a potentially large increase in invasive testing and diagnosis of myocardial infarction.
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Affiliation(s)
- Gerald Fitzgerald
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - R N Kerley
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
| | - Thomas J Kiernan
- Department of Cardiology, University Hospital Limerick, Limerick, Ireland
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24
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Belley-Cote EP, Whitlock RP, Ulic DV, Honarmand K, Khalifa A, McClure GR, Gibson A, Alshamsi F, D'Aragon F, Rochwerg B, Duan E, Savija N, Karachi T, Lamontagne F, Kavsak P, Cook DJ. The PROTROPIC feasibility study: prognostic value of elevated troponins in critical illness. Can J Anaesth 2019; 66:648-657. [PMID: 31037586 DOI: 10.1007/s12630-019-01375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 11/22/2018] [Accepted: 11/26/2018] [Indexed: 10/26/2022] Open
Abstract
PURPOSE Elevated cardiac troponin concentrations in people with critical illness are associated with an increased risk of death. We aimed to assess the feasibility of a larger study to ascertain the utility of cardiac troponin as a prognostic tool for mortality in critically ill patients. METHODS Patients admitted to participating intensive care units during the one-month enrolment period were eligible. We excluded cardiac surgical patients and patients who were admitted and either died or were discharged within 12 hr. In enrolled patients, we measured high-sensitivity cardiac troponin I (hs-cTnI) and obtained electrocardiograms to ascertain the incidence of myocardial infarction (MI) and isolated troponin elevation. Our feasibility objectives were to measure recruitment rate, the proportion of patients who consented under a deferred consent model, and time required for data collection and study procedures. RESULTS Over a four-week enrolment period, 280 patients were enrolled using a deferred consent model. We obtained subsequent consent from 81% of patients. Study procedures and data collection required 1.7 hr per participant. Overall, 86 (38%) suffered a MI, 23 (10%) had an isolated hs-cTnI elevation, and 117 (52%) had no hs-cTnI elevation. The crude hospital mortality rate was 10% without an hs-cTnI elevation, 29% with an isolated hs-cTnl elevation (relative risk [RR]) 2.2; 95% confidence interval [CI], 1.0 to 6.0) and 29% with an MI (RR, 2.6; 95% CI, 1.4 to 5.1). CONCLUSION Myocardial injury with elevated hs-cTnI concentrations and MIs occur frequently during critical illness. This pilot study has established the feasibility of conducting a large-scale investigation addressing this issue.
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Affiliation(s)
- Emilie P Belley-Cote
- Department of Medicine, McMaster University, Hamilton, ON, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada. .,Population Health Research Institute, Hamilton, ON, Canada. .,David Braley Cardiac, Vascular and Stroke Research Institute, 237 Barton St. E., Hamilton, ON, L8L 2X2, Canada.
| | - Richard P Whitlock
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada.,Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Diana V Ulic
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Kimia Honarmand
- Department of Medicine, Western University, London, ON, Canada
| | - Abubaker Khalifa
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Graham R McClure
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Andrew Gibson
- Department of Medicine, William Osler Health System, Brampton, ON, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, UAE University, Ain, UAE
| | | | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Erick Duan
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Nevena Savija
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
| | - Tim Karachi
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Peter Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Deborah J Cook
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Population Health Research Institute, Hamilton, ON, Canada
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25
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van den Bersselaar LR, van der Hoeven JG, de Jong B. Suicide after inhaling a pyrethrins containing insecticide spray. BMJ Case Rep 2019; 12:12/4/e227936. [PMID: 30996064 DOI: 10.1136/bcr-2018-227936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Pesticide self-poisoning is rare in developed countries. We report a suicide case after inhalation of a pyrethrins containing insecticide spray. The patient presented at the emergency department with respiratory failure. Despite mechanical ventilation, he developed severe pulmonary inflammation with a systemic inflammatory response syndrome and died 5 days later. Studies reporting on acute pyrethrins or pyrethroids insecticide poisoning in both occupational and non-occupational cases usually describe mild and self-limiting respiratory symptoms as the predominant symptom. Severe or fatal cases of pyrethrins or pyrethroids poisoning are very rare. Patients with asthma or allergies are apparently more at risk for severe symptoms. In these cases, early and aggressive treatment with bronchodilatators, steroids, antihistamines and epinephrine should be considered.
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Affiliation(s)
| | - J G van der Hoeven
- Department of Intensive Care Medicine, Radboudumc, Nijmegen, The Netherlands
| | - B de Jong
- Department of Intensive Care Medicine, Gelre Ziekenhuizen, Apeldoorn, The Netherlands
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26
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Vafaie M, Stoyanov KM, Giannitsis E. [Diagnosis of myocardial infarction in critically ill, ventilated patients]. Med Klin Intensivmed Notfmed 2019; 114:290-296. [PMID: 30923853 DOI: 10.1007/s00063-019-0572-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 01/20/2019] [Accepted: 03/04/2019] [Indexed: 11/25/2022]
Abstract
Elevated cardiac troponin values are frequently observed in critically ill patients. These are often not due to myocardial infarction (MI) but caused by various other etiologies of myocardial injury. Understanding the etiology of any troponin elevation is of enormous importance for management and therapy. According to the fourth version of the Universal Definition of MI, myocardial injury is present if at least one troponin value is above the 99th percentile upper reference limit and considered acute, when a rise and/or fall occurs. Patients with acute MI are a subgroup of patients with acute myocardial injury, who present in an ischemic clinical context. Variables defining the clinical criteria of MI include symptoms of ischemia, presumably new electrocardiographic (ECG) changes or imaging evidence of new loss of viable myocardium or regional wall motion abnormalities, or detection of an intracoronary thrombus. In critically ill or mechanically ventilated patients, the diagnosis of MI is challenging due to limitations in history taking, co-existence of comorbidities, overlapping symptoms and equivocal or unspecific ECG changes. This article presents the diagnostic criteria of the Universal MI definition, discusses subtypes of MI and focuses on various differential diagnoses. Furthermore, implications of diagnosis of MI in critically ill patients, especially regarding the use of ECG and troponin assays, are discussed.
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Affiliation(s)
- M Vafaie
- Medizinische Klinik III, Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland.
| | - K M Stoyanov
- Medizinische Klinik III, Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
| | - E Giannitsis
- Medizinische Klinik III, Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
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27
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Kaji DA, Zech JR, Kim JS, Cho SK, Dangayach NS, Costa AB, Oermann EK. An attention based deep learning model of clinical events in the intensive care unit. PLoS One 2019; 14:e0211057. [PMID: 30759094 PMCID: PMC6373907 DOI: 10.1371/journal.pone.0211057] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Accepted: 01/07/2019] [Indexed: 12/20/2022] Open
Abstract
This study trained long short-term memory (LSTM) recurrent neural networks (RNNs) incorporating an attention mechanism to predict daily sepsis, myocardial infarction (MI), and vancomycin antibiotic administration over two week patient ICU courses in the MIMIC-III dataset. These models achieved next-day predictive AUC of 0.876 for sepsis, 0.823 for MI, and 0.833 for vancomycin administration. Attention maps built from these models highlighted those times when input variables most influenced predictions and could provide a degree of interpretability to clinicians. These models appeared to attend to variables that were proxies for clinician decision-making, demonstrating a challenge of using flexible deep learning approaches trained with EHR data to build clinical decision support. While continued development and refinement is needed, we believe that such models could one day prove useful in reducing information overload for ICU physicians by providing needed clinical decision support for a variety of clinically important tasks.
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Affiliation(s)
- Deepak A. Kaji
- Icahn School of Medicine at Mount Sinai, Department of Orthopaedics, New York, NY, United States of America
| | - John R. Zech
- Icahn School of Medicine at Mount Sinai, Department of Orthopaedics, New York, NY, United States of America
| | - Jun S. Kim
- Icahn School of Medicine at Mount Sinai, Department of Orthopaedics, New York, NY, United States of America
| | - Samuel K. Cho
- Icahn School of Medicine at Mount Sinai, Department of Orthopaedics, New York, NY, United States of America
- Icahn School of Medicine at Mount Sinai, Department of Neurological Surgery, New York, NY, United States of America
| | - Neha S. Dangayach
- Icahn School of Medicine at Mount Sinai, Department of Neurological Surgery, New York, NY, United States of America
- Icahn School of Medicine at Mount Sinai, Department of Neurology, New York, NY, United States of America
| | - Anthony B. Costa
- Icahn School of Medicine at Mount Sinai, Department of Neurological Surgery, New York, NY, United States of America
| | - Eric K. Oermann
- Icahn School of Medicine at Mount Sinai, Department of Neurological Surgery, New York, NY, United States of America
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28
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Abdalla M, Sohal S, Al-Azzam B, Mohamed W. Effect of Troponin I Elevation on Duration of Mechanical Ventilation and Length of Intensive Care Unit Stay in Patients With Sepsis. J Clin Med Res 2019; 11:127-132. [PMID: 30701005 PMCID: PMC6340681 DOI: 10.14740/jocmr3713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 12/26/2018] [Indexed: 12/11/2022] Open
Abstract
Background Sepsis is a leading cause of mortality and morbidity. Recent studies suggest that troponin elevation is associated with increased mortality in sepsis patients. The purpose of this study is to determine the effect of troponin elevation on mechanical ventilation duration and intensive care unit (ICU) length of stay in patients with sepsis. Additionally, we investigated the association between troponin elevation and septic shock. Methods The study is a retrospective observational cohort study, conducted in a community teaching hospital between October 2015 and April 2018. All adult ICU patients with sepsis who required invasive mechanical ventilation were included. Primary outcomes were mechanical ventilation duration and ICU length of stay. Secondary outcomes were hospital length of stay, in-hospital mortality and association with septic shock. Results A total of 125 patients were included. Troponin was elevated in 36% (45/125) of the patients. Duration of mechanical ventilation in hours was longer for troponin-positive group (troponin positive: 55.6 h vs. troponin negative: 49.6 h, 95% CI 0.001 - 0.063, P = 0.032). ICU length of stay was similar (troponin positive: 4.6 days vs. troponin negative: 4.3 days, 95% CI 0.130 - 0.270). Septic shock had higher occurrence in elevated troponin group (troponin positive: 62.2% (28/45) vs. troponin negative: 43.8% (35/80), risk ratio (RR) 1.4, P = 0.04, 95% CI 1.015 - 1.99). Conclusions Troponin elevation was associated with longer duration of mechanical ventilation in patients admitted to ICU with sepsis. Troponin elevation was associated with higher risk for development of septic shock. No significant effect was observed in ICU length of stay and hospital length of stay.
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Affiliation(s)
| | - Sumit Sohal
- Presence Saint Francis Hospital, Evanston, IL, USA
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29
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Gotur DB. Sepsis in a Panorama: What the Cardiovascular Physician Should Know. Methodist Debakey Cardiovasc J 2018; 14:89-100. [PMID: 29977465 PMCID: PMC6027712 DOI: 10.14797/mdcj-14-2-89] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Sepsis accounts for an estimated 30 million cases and 6 million deaths globally each year. According to a multidisciplinary task force convened by the Society of Critical Care Medicine and European Society of Intensive Care Medicine, sepsis is defined as life-threatening organ dysfunction due to a dysregulated host response to infection. Sepsis is a medical emergency, so much so that the World Health Organization made it a global health priority. Since patients with cardiovascular diseases have unique risk factors for sepsis, prompt and accurate diagnosis is critical. In this regard, the sepsis-specific Sequential Organ Failure Assessment (SOFA) helps clinicians identify the organ dysfunction and predict outcomes. Sepsis management is grouped into specific interventions called bundles, and completion of each bundle element is time sensitive. The U.S. Centers for Medicaid and Medicare Services and some state-specific regulations have made compliance with these bundles reportable as a quality measure. The updated Surviving Sepsis Campaign Hour-1 bundle recommends that lactate measurement, blood cultures procurement, broad spectrum antibiotics administration, resuscitation with 30 mL/kg crystalloid, and vasopressor initiation for hypotension all be initiated within 1 hour of time zero, which is from the time of triage in the emergency department or from sepsis diagnosis. Septic shock is defined as hypotension with a mean arterial pressure less than 65 mm Hg, requiring vasopressors despite adequate fluid resuscitation and/or lactic acid levels above 2 mmol/L. Both fluid resuscitation and clinical re-evaluation with lactate measurement guide the fluid and vasopressor therapy. Specific guidelines exist for organ support that address mechanical ventilation, blood transfusions, vasopressor choices, and nutrition.
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